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CASE STORY
IMPOTENCE, also known as erectile dysfunction (ED), is the inability to achieve and sustain an erection sufficient for sexual intercourse. ED is the most common male sexual disorder, affecting some 30 million males in this country.
Occasional failure to achieve an erection, whether as a result of too many drinks, stress, being extremely tired, or lack of desire, is not unusual for men at any age. Recurring difficulty achieving and sustaining an erection is another matter, and is generally the result of ongoing physical problems rather than temporary, situational conditions. Failure to achieve erection less than 20% of the time is not unusual and treatment is rarely needed. More than 50% of the time indicates a problem that will worsen without appropriate treatment.
ED is not necessarily a normal part of aging. Some men never develop ED, but the odds of being affected by it increase with age. Older men may need more stimulation to achieve erection, penis sensitivity may diminish, and orgasms may not be as strong, but older men should still be able to get and sustain an erection and enjoy a satisfying sex life.
ED is caused by physical and psychological factors and often by a mixture of both. The most common physical causes of ED are:
- Diseases that affect blood flow: hardening of the arteries, hypertension, high cholesterol
- Diabetes
- Nerve and brain diseases: strokes, multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, and spinal cord injuries
- Injury to the penis
- Chronic illness
- Some medications, including certain drugs for the treatment of depression and high blood pressure
- Some treatments including radiation treatment for prostate cancer
- Peyronie’s disease
- Tobacco, alcohol and recreational drug use
Psychological factors are estimated to be responsible for 10% to 20% of all cases of ED, often as a secondary reaction to physical causes. Psychological causes may include:
- Stress
- Depression
- Performance anxiety
- Low self-esteem
- Guilt
- Relationship conflicts
- Poor sexual communication
- Indifference
The good news is that ED can be successfully treated. If you are experiencing problems with erections, consult a physician to determine if ED is present. If it is, once its cause is identified, treatment plans can be made. There are many ways ED can be treated, including oral medications, sex therapy, penile injections and surgery.
Sex therapy is usually helpful in conjunction with any of the treatments you and your doctor choose. ED takes more than a physical toll; it also takes an emotional toll. It is common for men with ED to feel anger, frustration, or lack of confidence. It can also have emotional impact on the partner: feeling undesirable, feeling responsible for “fixing it” and feeling frustrated are common partner reactions to ED.
Depression medication, performance anxiety and treatment for prostate cancer are common causes of ED.
ROBERT: Impotence as a Result of Prostate Cancer Treatment
Robert and Betty, a handsome couple in their fifties, came to counseling because they wanted to regain the intimacy they knew in their relationship before Robert was diagnosed with and treated for prostate cancer the previous year. After undergoing radiation treatment for the cancer, Robert began having problems achieving and maintaining erections.
Robert and Betty had been married for 14 years. It was her first marriage and Robert’s second marriage. He had 2 grown daughters from his first marriage but he and Betty had no children together. Robert and Betty spoke of their stable, happy relationship and their previously satisfying, active sex life.
After radiation treatment, as their sex life gradually began to change, they became more and more emotionally distant. They came to me for help with recapturing the emotional and physical intimacy they had enjoyed before Robert’s cancer therapy.
As they presented their problem to me, they said that they hadn’t been comfortable discussing their concerns with each other for fear of hurting or offending the other. It took them a couple of sessions to begin, slowly and carefully, to reveal what they had been experiencing as a result of their changed sex life.
Robert had assumed that he would always be able to function sexually regardless of his physical or psychological state. But as his sexual desire decreased, as he found that he needed more stimulation to become aroused, and as he could no longer have erections on demand, he became more and more focused on getting and keeping erections. His concern with his erections consumed him and he tended less and less to Betty’s physical and emotional needs. In fact, his anxiety about erections escalated until he started to avoid situations that might lead to sex. He wanted to avoid disappointing Betty and himself. But he didn’t share his fears and anxieties with Betty.
Betty, a woman who had enjoyed an active sex life with her husband, suddenly felt rejected by his avoidance. Not knowing what he was experiencing, she started to doubt her sexual skills and attractiveness. She felt responsible for his erections; when they did not occur, she experienced a sense of failure. Little by little, she started to refrain from expressions of affection for fear of inducing pressure or guilt in Robert and anxiety and disappointment in herself. She kept these feelings a secret. Emotional distance grew between Robert and Betty as each felt rejected by the other.
Two months before their first visit to me, Robert discussed his erection problems with his doctor and the doctor prescribed Viagra. Robert was excited about the prospect of being able to depend on getting erections. Betty pretended to be enthusiastic but inwardly she felt she had failed him. She felt he was being forced to use “artificial means” for erections because she was no longer attractive to him. Betty was also turned off by the prospect of having to plan intercourse since Robert had to take the medication an hour before sexual relations.
Robert could now have erections and they could continue to have intercourse, but things just weren’t working out. Their sexual interaction, which had been so pleasurable and positive an experience, now became a source of anxiety and emotional distancing.
During the course of the counseling sessions, a dialog about all the above unexpressed fears and frustrations ensued. As they started to understand what the other was experiencing, they no longer felt responsible or guilty about their sexual problems. They began to see the problems as the natural result of the cancer therapy rather than of personal failure. It was now time to start working on regaining the physical and emotional intimacy they had lost.
To start the process of rebuilding intimacy, I gave them instructions on what I call pleasuring exercises. The goal of these exercises is not erections, intercourse or orgasm. The goal is to take the focus away from performance and focus on pleasure. There is to be no intercourse, no orgasms, no genital or breast touching for the first week of the pleasuring exercises.
I asked them to set aside a time during the day when they could spend an hour taking turns pleasuring each other. I suggested that before starting they set a relaxing mood with some of their favorite music, lighting candles and doing anything else they find relaxing. They were instructed to:
- Do pleasuring exercises 4 times a week.
- Take a shower or bath; go to bed with no clothes on.
- Divide the hour so one partner will receive and the other one will give pleasuring for 30 minutes; then switch roles for the next 30 minutes.
- Decide which one will receive first.
- Have the Receiver lie on her/his stomach. The Giver will caress gently, tenderly with hands and lips. The Giver is to caress the back of the head, the ears, the neck, the back, down the buttocks, inside of the thighs, the legs, and the feet. When the back is done, the Receiver turns over. The Giver caresses the front next paying special attention to the face, stroking gently, tenderly.
- Engage in NO BREAST or GENITAL touching.
- The Receiver relaxes, concentrates on his/her feelings and gives feedback to the Giver. If something doesn’t feel good, if it is too fast, too light, too hard, tell the Giver in a gentle way. If something feels particularly good, let the Giver know. FEEDBACK is very important.
- If arousal or erections occur, simply stop, hug, let arousal, erection subside, then start pleasuring again.
- When the first 30 minutes are up, change roles. Receiver gives, Giver receives for the next 30 minutes.
- Use imagination, add surprise touches (feathers, etc.).
- Have NO INTERCOURSE, NO ORGASM for the first week.
Betty and Robert were delighted with their experiences during their first week of pleasuring. Not having the pressure to perform freed them to relax and enjoy touching each other again. They were ready for the second week of pleasuring. Betty and Robert were asked to:
- Follow the instructions for the first week of pleasuring.
- Add non-demanding breast and genital stroking.
- No INTERCOURSE yet.
- Enjoy the arousal, the erections, climax if they came close to orgasm.
The second week of pleasuring each other brought Betty and Robert closer than they had felt since the cancer diagnosis and radiation treatment. They felt they were regaining their lost emotional closeness. Now I gave them instructions for the next week.
- Follow the instructions for the second week of pleasuring.
- Play to intercourse and climax.
On their next visit, Betty and Robert came in beaming. They felt emotionally and physically connected again. They were communicating with each other like they used to. We concluded that they had achieved the goal they had set for themselves at the beginning of therapy: restored sexual, emotional intimacy.
SEXPERT’S COMMENTS
Prostate cancer is not a cause of erectile dysfunction (ED). However, treatments for the disease can cause ED. Current methods of treatment include:
- Surgery with radical prostatectomy (removal of the entire prostate gland)
- Radiation treatment, whether by external beam or seed implant
- Hormone therapy
With radical prostatectomy, ED can begin immediately following the removal of the entire prostate gland and surrounding tissues, whether the nerve-sparing or non-nerve-sparing technique is used. If the nerve-sparing technique is used, recovery from ED may occur within the first year following the procedure. Recovery of erectile function after a non-nerve-sparing technique is unlikely but is possible.
After radiation therapy, the onset of ED is gradual and usually begins about six months following treatment. Without ED treatment, ED is usually permanent.
When hormone therapy is used, ED may occur approximately 2-4 weeks following the initiation of the therapy and manifests itself by a decreased desire for sex. Again, without ED treatment, ED is usually permanent.
Current ED treatment options for men who have received treatment for prostate cancer include:
- Viagra
- Penile injections
- Vacuum pumps
- Surgical implants
For some men and their partners, the above medical or technological assistance is sufficient to restore erectile functioning. For other couples, like Betty and Robert, the problem of impotence is not readily solved with these treatments. The man can have an erection and the couple can have intercourse, but the spontaneity that was part of the sexual experience has been lost. The couple, or one of the partners, becomes turned off. Or the initial cancer diagnosis, the following treatment, and the effect on the man’s erectile functioning create the emotional distancing which Betty and Robert experienced. It is these couples who will most benefit from sex counseling to help them cope with the changes in their sex life.
SUMMARY
- Prostate cancer is not a cause of erectile dysfunction (ED).
- Treatments for prostate cancer can cause ED.
- ED is not anyone’s fault.
- ED is treatable.
- Getting and maintaining an erection is not necessarily enough to have satisfying sex.
- Medical/technical ED treatments don’t bridge emotional distance.
- Sex counseling is a helpful adjunct to medical/technical ED treatment.
If you feel that you need more counseling for your difficulties than was offered
in the case story, you may contact me
about your specific problem via email
counseling or telephone counseling.
THANK YOU FOR YOUR INTEREST IN SEXPERT COUNSELOR.
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